Declaration Regarding Lost Share Certificate

This Declaration Regarding Lost Share Certificate is used by a shareholder who has lost or misplaced a stock certificate. This declaration sets out the specifics regarding the shares and must be signed in front of a notary.

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This Declaration Regarding Lost Share Certificate is for use by a shareholder who has lost a stock certificate. This declaration sets out the names of the corporation and shareholder, the number of the certificate and number of shares issued under the certificate. It also sets forth a declaration that the shares were not assigned or sold and that the certificate was mislaid, misplaced or inadvertently destroyed. A Declaration Regarding Lost Share Certificate will prove useful in the event the shareholder desires to either sell or vote the shares at a corporate meeting. This Declaration must be signed by the shareholder in the presence of a notary public.

This Declaration Regarding Lost Share Certificate includes the following:

Shareholder: Sets forth the names of the shareholder, corporation issuing the shares, lost certificate number and number of shares;

Declaration: Sets forth that shareholder has not sold or disposed of the shares and that the certificate has been misplaced, lost or destroyed;

Signature: The shareholder must sign the certificate in front of a notary public.

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This attorney-prepared packet contains:

General Instructions

Declaration Regarding Lost Share Certificate

State Law Compliance: This form complies with the laws of all states

Number of Pages4

DimensionsDesigned for Letter Size (8.5" x 11")

EditableYes (.doc, .wpd and .rtf)

UsageUnlimited number of prints

Product number#28508

This is the content of the form and is provided for your convenience. It is not necessarily what the actual form looks like and does not include the information, instructions and other materials that come with the form you would purchase. An actual sample can also be viewed by clicking on the "Sample Form" near the top left of this page.

Declaration Regarding Lost Share Certificate

IN THE MATTER OF share certificate number [Number of Lost Share Certificate] (the "Certificate") for [Number and Class of Shares (ie. 100 Common)] shares (the "Shares") in the capital stock of [Name of Corporation] (the “Corporation”) registered in the name of [Name of Shareholder] (the “Shareholder”).

I,[Name of Shareholder],of the City of [City of Residence of Shareholder], in the State of [State of Residence of Shareholder].

DO SOLEMNLY DECLARE THAT:

1.I am the registered owner of the Shares represented by the Certificate. The Shares are registered in my name on the books and registers of the Corporation.

2. I have not sold, transferred, assigned, pledged, hypothecated or otherwise encumbered or disposed of the Shares, nor have I in any way divested myself or been divested of the absolute ownership thereof.

3. The Certificate has been mislaid, lost, stolen or destroyed so that the same cannot be found or produced. At the time when it was mislaid, lost, stolen or destroyed, the Certificate had not been endorsed for transfer.

4. I make this solemn declaration for the purpose of inducing the Corporation to replace or cause to be replaced the Certificate, and to issue or cause to be issued a new certificate or certificates in my name in lieu of the Certificate, and I hereby declare that if the Certificate comes into my possession or control, I will immediately surrender the Certificate to the Corporation.

Declared on [Date (ie. July 31, 2002)].

[Name of Shareholder]

District of [District]:

On [Date (ie. July 31, 2002)], before me personally appeared [Name of Officer of Shareholder], to me known, who, being duly sworn, did say that Shareholder named above, and that the foregoing Declaration Regarding Lost Share Certificate was signed by him as a free act and deed.

Notary Public

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